Psychological Medicine (2015), 45, 1999–2012. © Cambridge University Press 2015 doi:10.1017/S003329171500015X
OR I G I N A L A R T I C L E
Predictors of persistent maternal depression trajectories in early childhood: results from the EDEN mother–child cohort study in France J. van der Waerden1,2*, C. Galéra3,4,5, M.-J. Saurel-Cubizolles2,6, A.-L. Sutter-Dallay4,7,8, M. Melchior1,2 and the EDEN Mother–Child Cohort Study Group† 1
Department of Social Epidemiology, INSERM UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, F-75013 Paris, France Sorbonne Universités, UPMC Université Paris 06, F-75005 Paris, France 3 Department of Child and Adolescent Psychiatry, Charles Perrens Hospital, F-33000 Bordeaux, France 4 Bordeaux University, F-33000 Bordeaux, France 5 INSERM U897, Center for Research in Epidemiology and Biostatistics, Prévention et Prise en Charge des Traumatismes, F-33000 Bordeaux, France 6 INSERM, UMR-S 953, Epidemiological Research on Perinatal Health and Women’s and Children’s Health, F-94807 Villejuif, France 7 INSERM U657, F-33000 Bordeaux, France 8 University Department of Adult Psychiatry, Charles Perrens Hospital, F-33000 Bordeaux, France 2
Background. Maternal depression in the pre- and postpartum period may set women on a course of chronic depressive symptoms. Little is known about predictors of persistently elevated depressive symptoms in mothers from pregnancy onwards. The aims of this study are to determine maternal depression trajectories from pregnancy to the child’s fifth birthday and identify associated risk factors. Method. Mothers (N = 1807) from the EDEN mother–child birth cohort study based in France (2003–2011) were followed from 24–28 weeks of pregnancy to their child’s fifth birthday. Maternal depression trajectories were determined with a semi-parametric group-based modelling strategy. Sociodemographic, psychosocial and psychiatric predictors were explored for their association with trajectory class membership. Results. Five trajectories of maternal symptoms of depression from pregnancy onwards were identified: no symptoms (60.2%); persistent intermediate-level depressive symptoms (25.2%); persistent high depressive symptoms (5.0%); high symptoms in pregnancy only (4.7%); high symptoms in the child’s preschool period only (4.9%). Socio-demographic predictors associated with persistent depression were non-French origin; psychosocial predictors were childhood adversities, life events during pregnancy and work overinvestment; psychiatric predictors were previous mental health problems, psychological help, and high anxiety during pregnancy. Conclusions. Persistent depression in mothers of young children is associated to several risk factors present prior to or during pregnancy, notably anxiety. These characteristics precede depression trajectories and offer a possible entry point to enhance mother’s mental health and reduce its burden on children. Received 22 September 2014; Revised 20 January 2015; Accepted 20 January 2015; First published online 13 February 2015 Key words: Longitudinal trajectories, maternal depression, risk factors.
Introduction Depression is a common mental health problem among women of childbearing age, with prevalence rates ranging from 10% to 32% (Ertel et al. 2011; Wang et al. 2011). The impact of depression is significant not only for women’s quality of life (Darcy et al. 2011), but also
* Address for correspondence: J. van der Waerden, PhD, INSERM UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Department of Social Epidemiology, F-75013 Paris, France. † Members of the EDEN Mother–Child Cohort Study Group are given in the Appendix. (Email: [email protected])
for their children’s developmental outcomes (Ertel et al. 2011; Turney, 2012). Most information on the occurrence of maternal depression comes from studies conducted during the perinatal period (pregnancy to 12 months after delivery) (Horwitz et al. 2009), although symptoms may persist or re-emerge later (Essex et al. 2001; Goodman, 2007), setting women on a course of chronic depressive symptoms which have especially deleterious consequences for children (Fihrer et al. 2009; Connelly et al. 2010; Turney, 2012). Risk factors for maternal depression (such as socioeconomic disadvantage, a prior history of mental disorders, stressful life events, poor social support, domestic violence, and pregnancy/obstetric complications) have
2000 J. van der Waerden et al. been well examined in the perinatal period (Koleva et al. 2011; O’Hara & McCabe, 2013; Seimyr et al. 2013). Yet, little is known about predictors of persistent depression in mothers. With few exceptions (Seto et al. 2005; Horwitz et al. 2009; Skipstein et al. 2010, 2012; Wang et al. 2011; Giallo et al. 2014; Woolhouse et al. 2015), longitudinal studies examining chronic mental health difficulties in women beyond the second-year postpartum are scarce. These studies found that depressive symptoms are disproportionately likely to persist in women who are young, belong to an ethnic minority group, are unemployed, have low social support, experience high parenting stress, and stressful life events. However, most initial data collection was conducted 10–20 years ago and there is need for contemporary data on this topic. With the exception of the work by Woolhouse et al. (2015), none of these studies included depressive symptoms occurring in pregnancy, even though these are prevalent (12.4%) and associated with risk of later depression (Banti et al. 2011; Gaillard et al. 2014; Vliegen et al. 2014). In order to gain better understanding of women’s longitudinal patterns of depression and associated early risk factors we focused on antenatal predictors for persistent maternal depression from pregnancy onwards. We used data from a community-based sample of mothers followed from pregnancy up to when the child was 5 years of age to (1) determine symptom trajectories; (2) identify sociodemographic, psychosocial and psychiatric predictors of maternal depression trajectories present before or during pregnancy.
Method Participants Data for this study come from the EDEN mother–child study, set up to assess the pre- and postnatal nutritional, social, and environmental determinants of infant and child development and health (Drouillet et al. 2009). Pregnant women were recruited before 24 weeks of gestation from two maternity wards (Poitiers and Nancy University hospitals in France) between September 2003 and January 2006. Exclusion criteria were multiple pregnancies, history of diabetes, inability to speak and read French or plans to move out of the study region within the next 3 years. Among eligible women, 55% agreed to participate. Of the 2002 women recruited during pregnancy, birth data were available for 1899 mother–infant pairs. From pregnancy onwards, mothers and children were followed nine times (pregnancy, birth, 4, 8, 12, 24 months, 3, 4 and 5 years) via face-to-face or self-completed questionnaires completed by the mothers. Data on the child’s birth characteristics were collected directly from medical records.
By the year 5 follow-up, data on maternal depression were available for 1190 participants. Attrition rates were highest for mothers who were of non-French origin, young, had low educational level, and at baseline were single, unemployed, had financial difficulties or experienced other life events, had low social support, reported childhood adversity, used tobacco, had a history of mental health problems. The study was approved by the Comité Consultatif de Protection des Personnes dans la Recherche Biomedicale (Ethics Committee, Kremlin Bicêtre Hospital) and by the Commission Nationale de l’Informatique et des Libertés [National Committee for Processed Data and Freedom (CNIL)]. Written consent was obtained from the mother for herself at inclusion and for her newborn child after delivery. Measures and procedures Maternal symptoms of depression Depressive symptoms during pregnancy and at 3 and 5 years follow-ups were assessed using the Center for Epidemiological Studies Depression (CES-D) questionnaire (Radloff, 1977). This previously validated 20-item questionnaire measures the number of depressive symptoms over the past week (score range 0–60) (Fuhrer & Rouillon, 1989; Joiner et al. 2005). A threshold of 516 is commonly used to identify individuals at risk for clinical depression. Depressive symptoms during the first year after the child’s birth (4, 8 and 12 months postpartum) were assessed using the Edinburgh Postnatal Depression Scale (EPDS), a 10-item questionnaire designed to detect postnatal depression (score range 0–30) (Cox et al. 1987). In this study we used the cut-off 512, which has been recommended for the French translation and has demonstrated its validity for research purposes (Guedeney & Fermanian, 1998; Teissedre & Chabrol, 2004). To identify trajectories of maternal depressive symptoms we needed to meaningfully combine the scores of both instruments, which have different possible symptom severity score ranges. Thus, the scores for each instrument were standardized to t scores (mean = 50, S.D. = 10), which allowed us to study them jointly as continuous measures. Predictors Based on the scientific literature we identified several sociodemographic, psychosocial and psychiatric characteristics potentially associated with maternal depression trajectories. Sociodemographic characteristics were: study centre (Poitiers v. Nancy), age (dichotomized at the sample mean
OR I G I N A L A R T I C L E
Predictors of persistent maternal depression trajectories in early childhood: results from the EDEN mother–child cohort study in France J. van der Waerden1,2*, C. Galéra3,4,5, M.-J. Saurel-Cubizolles2,6, A.-L. Sutter-Dallay4,7,8, M. Melchior1,2 and the EDEN Mother–Child Cohort Study Group† 1
Department of Social Epidemiology, INSERM UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, F-75013 Paris, France Sorbonne Universités, UPMC Université Paris 06, F-75005 Paris, France 3 Department of Child and Adolescent Psychiatry, Charles Perrens Hospital, F-33000 Bordeaux, France 4 Bordeaux University, F-33000 Bordeaux, France 5 INSERM U897, Center for Research in Epidemiology and Biostatistics, Prévention et Prise en Charge des Traumatismes, F-33000 Bordeaux, France 6 INSERM, UMR-S 953, Epidemiological Research on Perinatal Health and Women’s and Children’s Health, F-94807 Villejuif, France 7 INSERM U657, F-33000 Bordeaux, France 8 University Department of Adult Psychiatry, Charles Perrens Hospital, F-33000 Bordeaux, France 2
Background. Maternal depression in the pre- and postpartum period may set women on a course of chronic depressive symptoms. Little is known about predictors of persistently elevated depressive symptoms in mothers from pregnancy onwards. The aims of this study are to determine maternal depression trajectories from pregnancy to the child’s fifth birthday and identify associated risk factors. Method. Mothers (N = 1807) from the EDEN mother–child birth cohort study based in France (2003–2011) were followed from 24–28 weeks of pregnancy to their child’s fifth birthday. Maternal depression trajectories were determined with a semi-parametric group-based modelling strategy. Sociodemographic, psychosocial and psychiatric predictors were explored for their association with trajectory class membership. Results. Five trajectories of maternal symptoms of depression from pregnancy onwards were identified: no symptoms (60.2%); persistent intermediate-level depressive symptoms (25.2%); persistent high depressive symptoms (5.0%); high symptoms in pregnancy only (4.7%); high symptoms in the child’s preschool period only (4.9%). Socio-demographic predictors associated with persistent depression were non-French origin; psychosocial predictors were childhood adversities, life events during pregnancy and work overinvestment; psychiatric predictors were previous mental health problems, psychological help, and high anxiety during pregnancy. Conclusions. Persistent depression in mothers of young children is associated to several risk factors present prior to or during pregnancy, notably anxiety. These characteristics precede depression trajectories and offer a possible entry point to enhance mother’s mental health and reduce its burden on children. Received 22 September 2014; Revised 20 January 2015; Accepted 20 January 2015; First published online 13 February 2015 Key words: Longitudinal trajectories, maternal depression, risk factors.
Introduction Depression is a common mental health problem among women of childbearing age, with prevalence rates ranging from 10% to 32% (Ertel et al. 2011; Wang et al. 2011). The impact of depression is significant not only for women’s quality of life (Darcy et al. 2011), but also
* Address for correspondence: J. van der Waerden, PhD, INSERM UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Department of Social Epidemiology, F-75013 Paris, France. † Members of the EDEN Mother–Child Cohort Study Group are given in the Appendix. (Email: [email protected])
for their children’s developmental outcomes (Ertel et al. 2011; Turney, 2012). Most information on the occurrence of maternal depression comes from studies conducted during the perinatal period (pregnancy to 12 months after delivery) (Horwitz et al. 2009), although symptoms may persist or re-emerge later (Essex et al. 2001; Goodman, 2007), setting women on a course of chronic depressive symptoms which have especially deleterious consequences for children (Fihrer et al. 2009; Connelly et al. 2010; Turney, 2012). Risk factors for maternal depression (such as socioeconomic disadvantage, a prior history of mental disorders, stressful life events, poor social support, domestic violence, and pregnancy/obstetric complications) have
2000 J. van der Waerden et al. been well examined in the perinatal period (Koleva et al. 2011; O’Hara & McCabe, 2013; Seimyr et al. 2013). Yet, little is known about predictors of persistent depression in mothers. With few exceptions (Seto et al. 2005; Horwitz et al. 2009; Skipstein et al. 2010, 2012; Wang et al. 2011; Giallo et al. 2014; Woolhouse et al. 2015), longitudinal studies examining chronic mental health difficulties in women beyond the second-year postpartum are scarce. These studies found that depressive symptoms are disproportionately likely to persist in women who are young, belong to an ethnic minority group, are unemployed, have low social support, experience high parenting stress, and stressful life events. However, most initial data collection was conducted 10–20 years ago and there is need for contemporary data on this topic. With the exception of the work by Woolhouse et al. (2015), none of these studies included depressive symptoms occurring in pregnancy, even though these are prevalent (12.4%) and associated with risk of later depression (Banti et al. 2011; Gaillard et al. 2014; Vliegen et al. 2014). In order to gain better understanding of women’s longitudinal patterns of depression and associated early risk factors we focused on antenatal predictors for persistent maternal depression from pregnancy onwards. We used data from a community-based sample of mothers followed from pregnancy up to when the child was 5 years of age to (1) determine symptom trajectories; (2) identify sociodemographic, psychosocial and psychiatric predictors of maternal depression trajectories present before or during pregnancy.
Method Participants Data for this study come from the EDEN mother–child study, set up to assess the pre- and postnatal nutritional, social, and environmental determinants of infant and child development and health (Drouillet et al. 2009). Pregnant women were recruited before 24 weeks of gestation from two maternity wards (Poitiers and Nancy University hospitals in France) between September 2003 and January 2006. Exclusion criteria were multiple pregnancies, history of diabetes, inability to speak and read French or plans to move out of the study region within the next 3 years. Among eligible women, 55% agreed to participate. Of the 2002 women recruited during pregnancy, birth data were available for 1899 mother–infant pairs. From pregnancy onwards, mothers and children were followed nine times (pregnancy, birth, 4, 8, 12, 24 months, 3, 4 and 5 years) via face-to-face or self-completed questionnaires completed by the mothers. Data on the child’s birth characteristics were collected directly from medical records.
By the year 5 follow-up, data on maternal depression were available for 1190 participants. Attrition rates were highest for mothers who were of non-French origin, young, had low educational level, and at baseline were single, unemployed, had financial difficulties or experienced other life events, had low social support, reported childhood adversity, used tobacco, had a history of mental health problems. The study was approved by the Comité Consultatif de Protection des Personnes dans la Recherche Biomedicale (Ethics Committee, Kremlin Bicêtre Hospital) and by the Commission Nationale de l’Informatique et des Libertés [National Committee for Processed Data and Freedom (CNIL)]. Written consent was obtained from the mother for herself at inclusion and for her newborn child after delivery. Measures and procedures Maternal symptoms of depression Depressive symptoms during pregnancy and at 3 and 5 years follow-ups were assessed using the Center for Epidemiological Studies Depression (CES-D) questionnaire (Radloff, 1977). This previously validated 20-item questionnaire measures the number of depressive symptoms over the past week (score range 0–60) (Fuhrer & Rouillon, 1989; Joiner et al. 2005). A threshold of 516 is commonly used to identify individuals at risk for clinical depression. Depressive symptoms during the first year after the child’s birth (4, 8 and 12 months postpartum) were assessed using the Edinburgh Postnatal Depression Scale (EPDS), a 10-item questionnaire designed to detect postnatal depression (score range 0–30) (Cox et al. 1987). In this study we used the cut-off 512, which has been recommended for the French translation and has demonstrated its validity for research purposes (Guedeney & Fermanian, 1998; Teissedre & Chabrol, 2004). To identify trajectories of maternal depressive symptoms we needed to meaningfully combine the scores of both instruments, which have different possible symptom severity score ranges. Thus, the scores for each instrument were standardized to t scores (mean = 50, S.D. = 10), which allowed us to study them jointly as continuous measures. Predictors Based on the scientific literature we identified several sociodemographic, psychosocial and psychiatric characteristics potentially associated with maternal depression trajectories. Sociodemographic characteristics were: study centre (Poitiers v. Nancy), age (dichotomized at the sample mean
